Provider Demographics
NPI:1003345802
Name:KEYVAN TAVAKOLI, DDS, MDS, P.A.
Entity type:Organization
Organization Name:KEYVAN TAVAKOLI, DDS, MDS, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEYVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVAKOLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-922-5707
Mailing Address - Street 1:18964 N DALE MABRY HWY STE 103
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4913
Mailing Address - Country:US
Mailing Address - Phone:813-591-1568
Mailing Address - Fax:
Practice Address - Street 1:18964 N DALE MABRY HWY STE 103
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4913
Practice Address - Country:US
Practice Address - Phone:813-591-1568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN224871223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty